Internal iliac artery sacrifice during endovascular abdominal aortic aneurysm repair

Abstract

Aim: We aimed to assess the clinical outcomes of the internal iliac artery (IIA) coverage during endovascular abdominal aortic aneurysm repair (EVAR).

Methods: A retrospective observational study was conducted in patients managed with EVAR for the aorto-iliac aneurysmal disease. The IIA was sacrificed by extension of the stent-graft into the external iliac artery in the absence of the distal landing zone, while it was preserved if the landing zone was available.

Results: From 2002 to 2018, 540 patients underwent EVAR for aorto-iliac aneurysmal disease in our center. Sixty-five (12.04%, n = 65/540) had iliac aneurysm extension. Among these 65 cases, the IIA was not covered in 32 patients (IIA salvage/spared group), while they were covered in 33 patients (IIA sacrifice group). The IIA sacrifice group consisted of 25 unilateral and 8 bilateral coverages. There was 100% technical success and no 30-day mortality in both groups. The IIA sacrifice group had more postoperative complications in general when compared to the IIA salvage group, but they were not significant (P < 0.05). There were one patient with buttock claudication (P = 1.000) with bilateral IIA coverage, two cases of lower limb microembolization (P = 0.492) and one case of erectile dysfunction (P = 1.000) in IIA sacrifice group, while they were not seen in IIA salvage group. There was no ruptured iliac access, device-related malfunction, spinal cord ischemia or bowel ischemia in either group.

Conclusion: We found coverage of IIA aneurysmal extension during EVAR of AAA to be technically feasible and safe.

Keywords

Abdominal aortic aneurysm / Iliac artery aneurysm / endovascular abdominal aortic aneurysm repair / clinical outcomes

References

[1] Hosaka A,Kato I,Okubo N.Outcome after concomitant unilateral embolization of the internal iliac artery and contralateral external-to-internal iliac artery bypass grafting during endovascular aneurysm repair..J Vasc Surg2011;54:960-4

[2] Armon M,Whitaker S,Hopkinson B.Common iliac artery aneurysms in patients with abdominal aortic aneurysms..Eur J Vasc Endovasc Surg1998;15:255-7

[3] Albertini JN,Bouziane Z,Nourrissat G.Aneurysmal extension to the iliac bifurcation increases the risk of complications and secondary procedures after endovascular repair of abdominal aortic aneurysms..Ann Vasc Surg2010;24:663-9

[4] Lee WA,Berceli SA,Huber TS.Outcome after hypogastric artery bypass and embolization during endovascular aneurysm repair..J Vasc Surg2006;44:1162-8discussion 1168-9

[5] Machado RM,de Oliveira PNFP.Endovascular treatment of internal iliac artery aneurysms: single center experience..Braz J Cardiovasc Surg2016;31:127-31 PMCID:PMC5062737

[6] Chaikof EL,Harris PL.Reporting standards for endovascular aortic aneurysm repair..J Vasc Surg2002;35:1048-60

[7] Chaikof EL,Eskandari MK.The society for vascular surgery practice guidelines on the care of patients with an abdominal aortic aneurysm..J Vasc Surg2018;67:2-77.e2

[8] Ghosh J,Paravastu S,Walker MG.Contemporary management of aorto-iliac aneurysms in the endovascular era..Eur J Vasc Endovasc Surg2009;37:182-8

[9] Gray D,Reifferscheid V,Brunkwall JS.EVAR with flared iliac limbs has a high risk of late type 1b endoleak..Eur J Vasc Endovasc Surg2017;54:170-6

[10] Bannazadeh M,Forsyth A.Outcomes for concomitant common iliac artery aneurysms after endovascular abdominal aortic aneurysm repair..J Vasc Surg2017;66:1390-7

[11] Loth AG,Gafoor SA,Stelter WJ.Treatment of iliac artery bifurcation aneurysms with the second-generation straight iliac bifurcated device..J Vasc Surg2015;62:1168-75

[12] Gray D,Jakobs C,Gawenda M.Endovascular aneurysm repair of aortoiliac aneurysms with an iliac side-branched stent graft: studying the morphological applicability of the Cook device..Eur J Vasc Endovasc Surg2015;49:283-8

[13] Kouvelos GN,Antoniou GA,Verhoeven EL.Outcome after interruption or preservation of internal iliac artery flow during endovascular repair of abdominal aorto-iliac aneurysms..Eur J Vasc Endovasc Surg2016;52:621-34

[14] Marques de Marino P,Kouvelos G,Katsargyris A.Use of bilateral cook zenith iliac branch devices to preserve internal iliac artery flow during endovascular aneurysm repair..Eur J Vasc Endovasc Surg2019;57:213-9

[15] Donas KP,Cao P.Secondary procedures following iliac branch device treatment of aneurysms involving the iliac bifurcation: the pELVIS registry..J Endovasc Ther2017;24:405-10

[16] Farivar BS,Dias AP.Durability of iliac artery preservation associated with endovascular repair of infrarenal aortoiliac aneurysms..J Vasc Surg2017;66:1028-36.e18

[17] Bosanquet DC,Whitehurst L,Williams IM.Systematic review and meta-analysis of the effect of internal iliac artery exclusion for patients undergoing EVAR..Eur J Vasc Endovasc Surg2017;53:534-48

[18] Fatima J,Mendes BC.Pelvic revascularization during endovascular aortic aneurysm repair..Perspect Vasc Surg Endovasc Ther2012;24:55-62

[19] Libicher M,Bangard C.Occlusion of the internal iliac artery prior EVAR: comparison of coils and plugs..Vasc Endovascular Surg2012;46:34-9

[20] Mansour W,Sirignano P.Clinical and functional impact of hypogastric artery exclusion during EVAR..Vasc Endovascular Surg2016;50:484-90

[21] Mehta M,Ohki T.Unilateral and bilateral hypogastric artery interruption during aortoiliac aneurysm repair in 154 patients: a relatively innocuous procedure..J Vasc Surg2001;33:S27-32

[22] Iliopoulos JI,Thomas JH.Hemodynamics of the hypogastric arterial circulation..J Vasc Surg1989;9:637-41discussion 641-2

[23] Fujioka S,Morimura H.Outcomes of extended endovascular aortic repair for aorto-iliac aneurysm with internal iliac artery occlusion..Ann Vasc Dis2017;10:359-63 PMCID:PMC5835440

[24] Kontopodis N,Papadopoulos G,Tsetis D.Embolization or simple coverage to exclude the internal iliac artery during endovascular repair of aortoiliac aneurysms? Systematic review and meta-analysis of comparative studies..J Endovasc Ther2017;24:47-56

[25] Bharwani N,Choke E.Is internal iliac artery embolization essential prior to endovascular repair of aortoiliac aneurysms?.Cardiovasc Intervent Radiol2008;31:504-8

[26] Chun JY,Abbasi MA.Embolization of the internal iliac artery before EVAR: is it effective? Is it safe? Which technique should be used?.Cardiovasc Intervent Radiol2014;37:329-36